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Complementary and alternative medicine in geriatric psychiatry by Dr. Param


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CAM in Geriatric psychiatry presented in teaching class in Department of Psychiatry FMMC- Mnagalore

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Complementary and alternative medicine in geriatric psychiatry by Dr. Param

  2. 2. INTRODUCTION  What most medical practitioners conceive of as “health care”(modern)- is actually quite in its infancy compared to  many practices aimed at curing or ameliorating illness  that developed across the world for many centuries past.
  3. 3. TRADITIONAL V/S NONTRADITIONAL HEALTH CARE  Western countries have experienced a notable growth in the use of nontraditional health care practices, usually coined “complementary and alternative medicine” (CAM).  Many people have theorized that ,  patients more and more find traditional health care impersonal and inadequate to address the aspects of their health and wellness  that cannot be measured in blood levels or visualized by radiological tests.
  4. 4. The wide spread adoption of CAM practices led the U.S government to establish Within the National Institute of Health(NIH).
  5. 5.  The National Center for Complementary and Alternative Medicine (NCCAM) has organized CAM in into five broad (at times overlapping) categories:  1. Biologically based therapies,  2. Mind–body therapies,  3. Energy-based therapies,  4. Body-based/manipulative therapies, and  5. Whole medical systems (e.g., homeopathy or Ayurveda).
  6. 6.  Biologically based therapies:  Ginko biloba,  Melatonin,  Vit. E,  Omega-3 fatty acids, {docosahexaenoic acid [DHA] and eicosapentaenoic acid [EPA] =anti-inflammatory effects }  St. John's wort, {Perforate/Common St. John’s wort [Hypericum perforatum ]}  Ginseng [geus- Panax= All healing., in North America, northeast China, Korea, Bhuthan, estern Siberia, Vietnam] ,  Garlic extract  Green Tea {-Camellia sinensis -fermentation process -> one type GT polyphenol, epigallocatechin-3-gallate (ECGC), with anti-inflammatory properties }  Chamomile/ camomile [herbal tea/herb infusions  Huperzine A (HupA) – [sesquiterpene alkaloid from club-moss/firmoss Huperzia serrata (qien chen ta),]  Coenzyme Q (CoQ) [obligatory cofactor of mitochondrial uncoupling proteins & bioenergetic agent in mitochondrial respiratory chain]  Acetyl-L-Carnitine [shuttling acetyl groups and fatty acids from cytoplasm into mitochondria, thereby facilitating energy production].  α-Lipoic acid  S-Adneosylmethionine
  7. 7.  Mind–body therapies:  Breathing exercises  Meditation/Relaxation  Music Therapy  Qigong  Yoga  Tai Chi  Energy-Based Therapies  External qi Therapy (External Qigong)  Acupuncture  Light Therapy  Auricular Therapy
  8. 8.  Body-based/manipulative therapies:  Massage  Acupressure  Whole medical systems  homeopathy  Ayurveda  Siddha
  9. 9.  Factors associated with an increased likelihood of CAM use include  higher educational level,  poorer overall health,  congruence with personal values and philosophical orientations to health, and  symptoms of pain, depression, or anxiety.
  10. 10. EPIDEMIOLOGY OF CAM USE  Older Adults  Among the top ten nonvitamin/nonmineral supplements used in the 2002 survey,  several have potential relevance to psychiatric disorders among older adults,  In - the 2002 National Health Interview Survey,  the overall one-year prevalence of CAM use among U.S. adults was 62 %, and  among age- 60 & above = 65 to 70%.  with prayer for health purposes, biological supplements, and relaxation exercises being the most popular.
  11. 11.  Pain and Psychological symptoms (e.g., depression, anxiety, insomnia, or memory loss)  as the most common symptoms for which they use CAM.  The 2000 Wave of Health/Retirement survey (included multivitamins and mineral supplements)  higher one-year prevalence - older adults 88%.
  12. 12.  when prayer and megavitamin use were excluded,  CAM use steadily declined with increasing age,  from 33% among 60- to -69 year-olds to  15% among those age 85 years & >.  - different patterns of CAM use among certain subpopulations of older adults  increased energy-based practices in Asian Americans,  use of curanderos in Hispanic Americans, and  spiritual health practices in African Americans.
  13. 13.  Persons with Mental Disorders  In national samples of general Adult populations,  persons with Depression and Anxiety (esp. Panic disorder) symptoms use CAM therapies more.  Biological supplements, including herbs,  mind–body practices, and spiritual practices  were the most commonly used therapies by those with depression, anxiety, or both.
  14. 14.  2002 National Health Interview Survey  ~ 82% of older adults with self-reported Depression or Anxiety had used CAM within the prior year  (65% of older adults without these symptoms).  The most common therapies were  Spiritual practices, Relaxation techniques, and Nonvitamin/nonmineral biological supplements.  A smaller regional study   older adults, who used CAM,  higher scores for depression, pain, and sleep disturbance,  with mind–body practices, esp. for depression.
  15. 15. CAM THERAPIES IN DEMENTIA  In one study, 55% of caregivers for persons with Alzheimer's disease had given their loved ones at least one CAM therapy (most commonly high-dose vitamins),  in an effort to improve their cognition.  Most studies of CAM in dementia have substantial flaws in their methodology (e.g., small sample size or inadequate control groups).
  16. 16. BIOLOGICALLY BASED TREATMENTS   most research in dementia,  usually these treatments are focused on the cognitive and functional symptoms of dementia,  esp. on neuropsychiatric symptoms...  Common putative mechanisms of action for these CAM,.. include  Altered neurotransmitter (especially acetylcholine [ACh]) function,  Antioxidant properties, and  Antiplatelet/anticoagulant properties
  17. 17.  1. Ginkgo Biloba:  in doses of 120 to 240 mg/day is the most studied and most widely used...  E.g. standardized EGB 761 = 22 to 27% ginkgo flavonoids, 5 to 7% terpene lactones, and 2.6 to 3.2% bilobalide.  MOA:  Antioxidant properties, may enhance cerebral blood flow via  antagonism of platelet activating factor and alterations in vascular tone, and  ~ enhance glucose metabolism.  Increased Alpha-wave and Decreased Delta-wave activity on EEG, [similar to acetylcholinesterase (AChE) inhibitors]
  18. 18.  2007 study   the effects of ginkgo on neuropsychiatric symptoms among 400 persons with Alzheimer's disease, vascular dementia, or mixed Alzheimer's disease/vascular dementia and a Neuropsychiatric Inventory (NPI) score >5   improvement in Apathy, Anxiety, Irritability, Depression, and Sleep,  There is also one report of improved depression with EGB 761 versus placebo  as an augmentation to prescription Antidepressant treatment  in persons with “cerebral insufficiency.”
  19. 19.  ?Side effects:  Gastrointestinal (GI) upset, Skin reactions, Headache, and bleeding complications (e.g., subdural hematoma).   and may have important interactions with prescription Anticoagulant medications.  The largest and best-designed study for ginkgo's effects (at 120 mg/day) on cognition in cognitively intact older adults was negative.  probably best preserved for  those who cannot tolerate prescription agents or  for persons insistent on using a CAM, because of their personal health philosophies.
  20. 20.  2. Huperzine A  HupA is a plant-based alkaloid - from the club moss Huperzia serrata (qien chen ta),  has been used for centuries in China as a folk medicine for  fever, inflammation, analgesia, and even schizophrenia and myasthenia gravis.  strong in vitro inhibition of AChE,  is sold in the United States as a “dietary supplement.”  stereoselective actions, because the (-)HupA enantiomer is a much more potent inhibitor of AChE than the (+)HupA enantiomer.
  21. 21.  ?  HupA is more selective for Central than peripheral AchE and  more selective for the Tetrameric (G4) isoform of AchE than Donepezil (Aricept) and Rivastigmine (Exelon).  Others:  can reduce amyloid (Aβ) generation,  has antioxidant properties,  antiapoptotic via upregulation of Bcl-2 gene expression (a gene involved in cell cycle regulation) in Aβ-induced oxidative stress models in animals.  may also block glutamate-induced toxicity, similar to - memantine.
  22. 22.  ?A recent multicenter, double-blind, randomized, controlled trial (RCT) in China - versus placebo among persons with DSM- IV-TR) possible or probable Alzheimer's disease.   promising results wt improvement in cognition (on Mini Mental State Exam [MMSE] scores and Alzheimer Disease Assessment Scale—Cognitive [ADAS-cog] scores), measures of ADLs, and neuropsychiatric symptoms as measured by the ADAS-noncognitive subscale (e.g. depression, delusions, or repetitive activities).
  23. 23.  Adverse effects likely resemble those of prescription AChE inhibitors   GI upset,   Insomnia  Bradicardia
  24. 24.  3. Melatonin:  Pineal gland.. endogenous hormone darkness derivative of serotonin.   in-vitro potent antioxidant properties.  Natural biological function regulation of circadian rhythms sleep disorders (cognition)  in dementia; (studies)  Also - antioxidant properties cognition..  But, at least two well-designed RCTs failed to find significant benefits..  although caregivers in one study - rated subjective sleep quality as better with 2.5 mg of melatonin at night compared to placebo.
  25. 25.  average recommended dose of melatonin is 1 to 3 mg at bedtime,  Potential adverse reactions:  Vasoconstrictive effects (demonstrated in coronary and cerebral arteries in animal studies) and  Iatrogenic depression
  26. 26.  4. Choto-San:   derived from the medicinal plant Uncaria sinensis,   traditional Japanese medicine.  Proposed MOA:  effects of its Phenol and Indole alkaloid constituents on inhibition of intracellular calcium influx  (? protecting against glutamate-induced excitotoxicity),  Antioxidant properties, and  Agonism of muscarinic type 1 (M1) ACh receptors.
  27. 27.  One blind RCT in  Alzheimer's disease and mixed Alzheimer's disease/vascular dementia,  Yielded positive results for cognition and ADL functioning.  A typical daily dose of choto-san would be 2.5 grams.  Possible adverse effects   Common GI upset,  rare Renal failure.
  28. 28.  5. Vitamin E  vitamins A and C, and vitamin E  antioxidant properties  studied for its potential therapeutic benefits for  Cardiovascular disease, Cancer, and Alzheimer's disease.   Was commonly used in mainstream treatment of Alzheimer's disease,  because of a landmark study showing that high-dose α- tocopherol (1,000 IU x twice daily)  delayed time to institutionalization and  preserved ADLs
  29. 29.  But, a meta-analysis (mostly among nondementia populations),  showed a slightly increased risk of mortality with high- dose (>400 IU/day) vitamin E versus placebo  (relative risk of death 1.04).  Most problematic side effects of high-dose vitamin E are  Bleeding or Bruising (via antagonism of vitamin-K-dependent clotting factors) and  GI upset.
  30. 30.  6. Coenzyme Q   is an obligatory cofactor of mitochondrial Uncoupling proteins and  A Bioenergetic agent in the mitochondrial respiratory chain.  CoQ and the structurally similar compound Idebenone   as therapeutic antioxidant agents in Neurodegenerative diseases:  Parkinson's disease and Huntington's disease,  but the largest Parkinson's disease study revealed no therapeutic effects for CoQ above those of placebo.
  31. 31.  Dose ranges in studies of CoQ have ranged from 360 to 1,080 mg/day, and  the overall safety has generally been comparable to that of placebo.  negative results of RCTs using Antioxidants may reflect  a lack of benefits when acting too late in the illness course
  32. 32.  7. Omega-3 Fatty Acids:  Inflammation is triggered in Alzheimer's disease by Aβ deposition.  Several epidemiological studies:  association between  reduced Alzheimer's disease risk with  increased Fish consumption {especially so-called fatty fish such as salmon (high in omega-3 fatty acids (primarily docosahexaenoic acid [DHA] and eicosapentaenoic acid [EPA]))}.  And also with,  the intake of anti-inflammatory compounds such as NSAIDs.
  33. 33.  But, RCT using the same ratio of DHA/EPA (1.7 mg/0.6 mg) in a combination pill and their effects on Neuropsychiatric symptoms when used as augmentation to AchE inhibitor therapy.  showed overall no improvement.  But, post-hoc subanalysis showed:  Agitation was reduced in apolipoprotein E4 (ApoE4) gene carriers and  Depression was reduced in ApoE4 noncarriers.  m/c s/e of omega-3 fatty acid supplementation:  Fishy aftertaste and  GI upset.
  34. 34.  8. Acetyl-L-Carnitine  Biological roles of this nutrient:  Shuttling acetyl groups and fatty acids from cytoplasm into mitochondria,  facilitating energy production.  ?MOA:  “Enhanced neuronal repair” via scavenging free radicals and  Stimulating nerve growth factor (NGF),  as a partial cholinergic agonist, and  being converted to Ach.  Some companies have marketed it as having general “antiaging” effects on mitochondria
  35. 35.  A small double-blind RCT in persons with mild cognitive impairment (MCI),   as positive for “behavior, attention, and memory”; and  another study,  some benefit in a few select cognitive domains.  But, the largest (431 participants) and best-designed study in Alzheimer's disease was essentially negative.  Suggested doses of acetyl-L-carnitine  2,500 to 3,000 mg/day.  ?adverse effects include GI upset, Agitation, Confusion, Depression, and Mania. (were comparable to those of placebo )
  36. 36.  9. Ginseng:  refer to several different plant species within the genus Panax, (Latin = “all-healing”)   long-standing use - in traditional Asian cultures for a variety of symptoms.  including fatigue, sexual dysfunction, and diabetes mellitus.  Asian ginseng (Panax ginseng) has been m/c studied as a single 200 mg dose  (some, as a combination of ginseng and ginkgo)  for improved performance on cognitive tasks in cognitively normal, mostly younger people.
  37. 37.  MOA for its immediate cognitive effects is  alteration of glucose metabolism.  Theoretical long-term effects:  Antioxidant and Anticoagulant properties.  No clinical trials in dementia populations could be found  Overall the evidence base for ginseng in dementia is absent.  Imp. Side effects:  Insomnia, Mania, Agitation, and excess Bleeding.
  38. 38.  10. Green Tea:  Tea leaves –from- plant Camellia sinensis,  changes in the fermentation process  different varieties of tea.  One variant, green tea = Polyphenol, Epigallocatechin-3-gallate (ECGC =~125 mg ),  with anti-inflammatory properties similar to Polyphenols identified in Blueberries.  possible neuroprotective effects in vitro via scavenging free radicals and iron-chelating properties.  also high in catechins, which have some reported effects on reducing obesity, which itself has been linked to Dementia risk.   no clinical trials with green tea or ECGC in dementia.
  39. 39. NONBIOLOGICALLY BASED CAM THERAPIES  Other CAM treatments have been mostly targeted at noncognitive symptoms  (e.g., depression, psychosis, agitation or aggression, or sleep disturbance) of Dementia.  Neuropsychiatric symptoms, consistently cause  Lower patient quality of life, Increased caregiver burden, Early institutionalization of patients, and High health care expenditures.  Also- side effects of Prescription medications for behavioral disturbances in dementia ,   to find effective Nonpharmacological treatments ... important public health priority
  40. 40.  1. Snoezelen:   a term for a System of multisensory stimulation,  (e.g., Lighting effects, Tactile surfaces, Meditative Music, and Smell of Essential oils),   in special rooms for 30 to 60 minutes per session.   originated in The Netherlands in the field of learning disability and autism with children,   adapted for use in dementia.  as this high stimulation sensory environment capitalizes on preserved sensorimotor capabilities in dementia and  allows patients to engage with stimuli that have low cognitive demands.   might be helpful for neuropsychiatric symptoms...
  41. 41.  A 2002 Cochrane review found two RCTs,   preliminarily promising short-term results for effects of Snoezelen on behavioral disturbances (e.g., apathy, mood, and restless or repetitive behaviors).  other study it to be comparable to “reminiscence therapy” (e.g., using newspapers or nostalgic items to allow a person to talk about old memories)  for acute agitation in dementia.  Also as an evidence grade of “B” for short-term effects.  Limitations:  Lack of widespread availability and  potentially high costs for maintaining the therapy.
  42. 42.  2. Music Therapy:   encompasses interventions using music in a variety of ways,  Including Passive listening of patient-selected versus Generic music and  Incorporation of patients into the Generation of music or song.  Specific qualities of music that are more or less therapeutic, are not well-established,  But, most common strategies are.  use of the patient's previous musical preferences,  use of music from earlier generations, and  use of generally “calming” music.
  43. 43.  A recent review of Nonpharmacological therapies for Behavioral disturbances in Dementia identified six RCTs assessing music therapy for agitation   were largely positive,  regarded use of music therapy for reducing acute agitation in dementia as evidence grade “B”  but only for very short time periods (e.g., during bathing).  Long-term effects were generally not assessed.
  44. 44.  3. Massage /Aromatherapy:  The techniques used (among the multiple varieties of massage) and  specifics of applying them (e.g., duration, frequency, and with or without aromatherapy)  have varied considerably across the few small studies of massage for Agitation in dementia.  mixed results,  ~ half of studies  beneficial effects on behavior (measured only over a very short time period).  A seemingly related technique, Therapeutic (Healing) Touch has been tried in at least one study for dementia with agitation.
  45. 45.  Therapeutic touch, is a bit of a misnomer,  because the intervention relies on the theory of manipulating energy fields in the person without necessarily contacting the patient's skin.  This technique draws upon ancient concepts of “universal energy” (e.g., prana in India or qi in China) and  has even less of an evidence base in dementia than traditional massage.
  46. 46.  Aromatherapy = use of essential oils extracted from plants for health purposes.  Trials as,  1.combined the application of the Essential oils with massage and  2. Inhaling the Aromas of the oils.  One study: the combination of aromatherapy (with lavender oil, commonly proposed to have sedating effects) and massage   less agitation than either condition alone.
  47. 47.  The most methodologically sound study of aromatherapy used lemon balm oil (Melissa officinalis) in a double-blind, placebo controlled trial for  managing agitation in severe dementia,   significant benefit for aromatherapy.  Also with, the oil was applied to the skin (without “massage”), and  when administered orally,  Systemic level of oil,  effects on ACh receptors.   benefit Cognition and Agitation in Dementia
  48. 48.  4. Bright Light Therapy:  Known for seasonal affective disorder in adults.  It uses Broad-spectrum white light (@ 2,000 to 10,000 lux) for 30 to 120 minutes,  usually in the Morning but in some studies in- evening.  Another variant  Dawn–dusk simulation,   Institutions, (e.g., skilled nursing facilities or hospital wards) vary the light intensity in large areas in an attempt to mimic natural diurnal variations in light intensity,
  49. 49.  Based on- on the fact that brain regions such as the suprachiasmatic nucleus that regulate circadian rhythms are known to degenerate in Alzheimer disease,  light is the most potent external regulatory stimulus for circadian rhythms,   institutionalized older adults with dementia receive little natural light exposure,   dementia patients often show disrupted circadian rhythms and sleep disturbances.  A 2004 Cochrane review of light therapy for sleep, behavior, or mood disturbances associated with dementia Inconclusive.
  50. 50.  Side effects of bright light therapy:  Occasional- Eye irritation and Headaches., and  theoretical concerns for long-term effects on the retina,  especially in older adults with pre-existing retinal pathology (e.g., macular degeneration).
  51. 51.  5. Exercise:  certain variations of exercise are often identified as CAM treatments (e.g., yoga or tai chi).  Several cohort studies   increased physical activity is associated with better cognitive functioning and less cognitive decline in older age,  but confirmatory prospective studies are needed.  Animal studies  Neurogenesis and Increased levels of Growth Factors such as BDNF.
  52. 52.  one cohort study examined the effects of self-reported mind–body exercises (e.g., tai chi or yoga) and cardiovascular exercise on learning and memory in older adults;  persons who reported practicing both types of exercise at least once a month outperformed  those practicing only one type of exercise and those with no regular exercise.
  53. 53.  6. Acupuncture:  This is western terminology for centuries-old Chinese medical practice,  as involving needle insertion into the skin.  Actually, Acupuncture proposes to manipulate qi, or bodily energy, as it flows through very specifically defined paths (“meridians”) in the body.
  54. 54.  Western medical research has, - focused on possible Biomedical mechanisms of action,  (e.g., needle insertion stimulating Endogenous Endorphin release).  Several reports of positive effects of acupuncture for Cognitive and Psychiatric symptoms of Vascular Dementia have emerged from China,  but a 2007 Cochrane Review found - no convincing evidence of positive benefit with problematic methodology.
  55. 55. CAM THERAPIES FOR LATE-LIFE DEPRESSION AND ANXIETY  Studies of CAM therapies (as with conventional treatments) are – more - in Younger and Middle-aged Adults  than in Older Adults for a variety of reasons.  Older Adults, - have more Confounding Medical Comorbidities and higher Susceptibility to Adverse effects than younger populations.
  56. 56. BIOLOGICALLY BASED CAM TREATMENTS  The medical literature among general adult populations indicates that the best evidence exists for  St. John's wort (Hypericum perforatum) and  S-adenosylmethionine (SAMe) as Antidepressants  Kava (Piper methysticum) as an Anxiolytic.
  57. 57.  St. John's Wort   is probably the best-known example of an herb proposed to treat depression,  plant extract has at least seven different chemical groups  e.g., hypericins, hyperforin, and flavonoids...  delimma to study..  Several possible antidepressant mechanisms of action...  most involving Modulation of Monoamine transmission similar to the mechanism of prescription antidepressants.
  58. 58.  The largest and most publicized trial of St. John's wort in Depression was conducted by the National Institute of Mental Health (NIMH),   compared the Herb to Placebo and Sertraline,  St. John's wort had no better efficacy than placebo and FDA-approved antidepressant - Sertaline
  59. 59.  A typical suggested daily dose of St. John's wort in younger adults is 900 to 1500 mg.  It induce cytochrome P450 3A4,  case reports of untoward interactions with Protease Inhibitors  (used to treat human immunodeficiency virus (HIV) infection and as an immunosuppressants ).  Side effects:  GI upset and Photosensitivity,  - little is known about possible side effects unique to elderly patients.
  60. 60.  S-Adneosylmethionine:  SAMe is a major methyl donor in the brain   in synthesis of Hormones and Neurotransmitters (e.g., monoamines),  intermediary compound in a chemical cycle with homocysteine, folate, and vitamin B12, and  ? anti-inflammatory properties.  Elevated Homocysteine levels and  decreased Folate levels   late-life depression.
  61. 61.  6 of 8 comparisons(+ve double blind-RCT) with placebo favored SAMe,  and equivalent efficacy(EEG changes) with Tricyclic Antidepressants.  Effective doses =from 200 to 1,600 mg/day in general Adult populations (higher range needed for Oral doses),  1,600 mg/day of oral SAMe costs hundreds of dollars per month...  side effects include  Insomnia, Anorexia or GI upset, Anxiety, and Mania.
  62. 62.  Kava (Piper methysticum) :  was originally used as a Ceremonial and Social drink in the South Pacific and  was also touted by Natives to have Analgesic properties.  Potentially bioactive compounds = kava lactones and α- pyrones,   exert Muscle relaxant, Anticonvulsant, and Sodium- channel-blocking effects in animal models.  Also, γ-aminobutyric acid (GABA) potentiation,  Dopamine antagonism, and  Modulation of Serotonin and Glutamate levels.
  63. 63.  Meta-analysis of 6 RCTs using the standardized kava extract WS1490 in doses of 150 to 300 mg/day  Found - more effective than placebo using Hamilton Anxiety Rating Scale scores in “nonpsychotic anxiety disorders.”  Also in - those over age 53.  safety issues have taken center stage,  Esp. reports of hepatic failure   have prompted its withdrawal in Germany and other countries.  And less serious long-term effects:  Facial swelling and Scaly rash.
  64. 64.  Other Biological CAM Treatments:  The only other RCTs identified in the review of biological CAM therapies for Depression or Anxiety were :  Two Negative trials in Postmenopausal women without specific psychiatric diagnoses (with Ginkgo biloba and Soy protein).  A Negative trial of four weekly vitamin B12 injections among older adults  with increased Methylmalonic acid,  But no specific psychiatric diagnosis and relatively low baseline depression severity scores.
  65. 65. MIND–BODY THERAPIES   “interventions that use a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms.”  There are - overlaps between this concept, and the concepts underlying many conventional psychotherapies.  But CBT, arguably the most evidence-based nonpharmacological intervention in modern psychiatry.  Mind–body therapies demonstrates the somewhat fluid definition of what constitutes CAM.
  66. 66.  Meditation/Relaxation:  Meditation has roots in various ethnocultural religious practices,  but in modern medical research essentially = any intentional exercise of focusing one's attention.  One common example:  Transcendental meditation,(was developed in India)   combines adopting certain postures (from hatha yoga) with attentional focus on a mantra (a word or syllable intended to instill one-pointed concentration).
  67. 67.  Two trials out of 6 trials of reviewed RCTs of CAM therapies for late-life depression or anxiety evaluated....  which combined progressive muscle relaxation with “meditative imagery”:   Positive results for Anxiety but not depression symptoms.  Mindfulness meditation, popularized by Jon Kabat-Zinn.  Mindfulness = “conscious allocation of attention in a nonjudgmental manner to awareness of the present moment.”  Little information exists for how useful - for older adults.  A recent review of studies of mindfulness-based stress reduction for anxiety and depression among Adults,   beneficial effects were equivocal and less pronounced in trials with adequate control groups.
  68. 68.  Relaxation therapy is a broad concept that may involve a variety of techniques designed to elicit a mental and physiological relaxation response,   includes a relative Dampening of Sympathetic tone and Increase in Parasympathetic tone  (e.g., lowered blood pressure, pulse, and respiratory rate).  The most common methods:  Controlled deep breathing exercises and  Progressive muscle relaxation.
  69. 69.  In a review of CAM therapies for anxiety,  has given an evidence of efficacy – grade I–II to Relaxation therapy in general adult populations with Anxiety disorders.  with positive meta-analyses for Generalized anxiety disorder and Panic disorder  (with relatively less evidence for PTSD, OCD, and Social anxiety disorder).  Occasionally reported Adverse Effects:  Paradoxical Increase in Anxiety,  Intrusive thoughts, and  Worsening of psychosis in predisposed individuals.
  70. 70.  Music Therapy:  Two RCTs were also identified for music therapy and its effect on Depression in older adults,  One with Major or Minor Depression and another on Mood symptoms in Parkinson's disease.  The American Music Therapy Association defines music therapy as “the use of music to Address Physical, Emotional, Cognitive, and Social needs of Individuals”,  to [with possible aims including to] promote wellness, manage stress, express feelings…and enhance memory.
  71. 71.  Music therapy can be Active (involving improvisation of music by therapists and patients using instruments and voice) or  Passive (with the patient at rest and generally aimed at promoting relaxation)  Both trials in older adults were positive.  Trials in Parkinson's disease, showed improvement in Mood and in Bradykinesia,  with active, improvisation-based music therapy.  warrant further research with improved methodology.  But, neither of these studies assessed anxiety symptoms.
  72. 72.  Qigong:  Qigong is an ancient Chinese practice using Movement, Affirmations, Breathing, Visualizations, and Meditation to “improve the flow of qi, the life force, and restore internal balance.”   may date back to 500 BCE,  considered a pillar of traditional Chinese medicine;   numerous variations and diverse schools of qigong.  The final two RCTs of mind–body therapies for late-life depression or anxiety tested qigong exercise for depressive symptoms.
  73. 73.  Both studies, used a practice entitled the “Eight-Section Brocades”,  which the authors assert is less cognitively and physically demanding than the similar and perhaps better known martial arts practice of tai chi.  The Second study had somewhat improved methodology showed positive results.  The ? therapeutic elements of such a practice, from a Western point of view:  the benefits of physical exercise on mood,  the meditative/relaxation aspects of the practice, and  the socialization/attention afforded by a group practice.
  74. 74.  *Example of Qigong Regimen: Eight-Section Brocades:  Prop up the sky with both hands to regulate the triple warmer  Draw a bow on both sides like shooting a vulture  Raise single arm to regulate spleen and stomach  Look back to treat five strains and seven impairments  Sway head and buttocks to expel heart-fire  Pull toes with both hands to reinforce kidney and waist  Clench fists and look with eyes wide open to build up strength and stamina  Rise and fall on tiptoes to dispel all diseases
  75. 75.  A comparable practice combining physical movement and mental focus is from ancient Indian tradition is Yoga,   includes a Practice of specified Postures, Breath work (Pranayama), and Sensory withdrawal (Pratyahara).  No RCTs of yoga for late-life depression or anxiety could be identified,  No well-conducted study has clearly demonstrated the efficacy of yoga for well-defined depressive or anxiety disorders.
  76. 76. ENERGY-BASED THERAPIES  This category includes Biofield therapies that,  according to NIH, “are intended to affect energy fields that purportedly surround and penetrate the human body.”   no conventional scientific definitions of these “fields of energy,”   often seem most foreign to Western medical practitioners.  one may consider qigong exercise and yoga as mind–body practices  because one sees how participants are using Mental focus in combination with Physical movement to affect bodily symptoms.
  77. 77.  the following “energy-based therapies” share in common the following:  (1) the idea that the therapeutic effects rest on manipulation of some energy fields associated with the human body and  (2) the manipulation of that energy is done by a therapist, with the patient as a passive participant  Some -include repetitive Transcranial Magnetic Stimulation (rTMS) as an energy-based CAM therapy
  78. 78.  External qi Therapy (External Qigong):  People who have become “masters” in their own personal practice of qigong are considered to be able to cultivate the ability to emit qi and thus direct it in therapeutic ways at the disturbed energy fields of other people.   is thought by its practitioners to help patients “clear qi blockages, expel negative qi, or balance the flow of qi in the body.”
  79. 79.  Two RCTs attempted to assess the effects of external qi therapy,   showed positive effects for external qi therapy on anxiety and depression symptoms (as well as pain severity),  but both had significant methodological shortcomings (use of treatment as usual as a control group) .
  80. 80.  Acupuncture:  ......   Many variations of acupuncture,  - Use of Moxibustion  (burning of moxa, a mugwort herb, to warm the acupuncture point) and  - Electroacupuncture  (in which acupuncture needles are attached to a device that generates electrical pulses and thus induces flow of an electrical current between two needle points).
  81. 81.  A recent review of five trials of acupuncture in general adult populations found acupuncture to be generally equivalent to prescription antidepressants.  A subsequent large trial failed to find differences between “depression-specific” acupuncture and “nonspecific acupuncture”  and overall low response rates (22 to 39%) among persons with major depression over 8 weeks.  One Chinese study with very vague methodology,   “mind-refreshing anti-depressive” acupuncture equivalent to treatment with doxepin and “routine” acupuncture.
  82. 82.  Light Therapy:  …  reviewed in a meta-analysis   found to have effect sizes similar to those of Antidepressants in both Seasonal and Nonseasonal Depression.  One RCT has failed show beneficial effects.
  83. 83. BODY-BASED/MANIPULATIVE THERAPIES  The most well-known example of a body-based CAM treatment is probably Chiropractic care.  was founded as a profession in the American Midwest by Daniel David Palmer in 1895.  But methods of spinal manipulation have been dated back to physicians including Hippocrates and Galen.  virtually no studies on chiropractic treatments and mental disorders.  Body-based therapies, includes Massage and Acupressure.
  84. 84.  Massage  ...- many varieties..  in general this refers to the  “smooth manual rubbing of muscles/soft tissue,” most commonly of the back, neck, and shoulders.  Demonstrated physiological effects of massage:  Increased muscle blood flow,  Decreased muscle stiffness,  Lowered heart rate and blood pressure,  Increased heart rate variability (a parasympathetic response),  Reduced cortisol levels, and Increased endorphins.
  85. 85.  Massage have become popular for use in Palliative care settings,  where alleviation of Pain, Nausea, and Psychological symptoms is often of utmost concern and   possible nonpharmacological means of doing so may be particularly appealing to some patients.  A small RCT among cancer patients (average age 73) receiving palliative care found that  massage was more effective than treatment as usual for depressive symptoms.
  86. 86.  Acupressure:  the therapeutic effects of manipulating bodily energy (qi),  using physical pressure is applied by the hand or elbow in a manner that resembles certain massage therapies.  only RCT among older adults with depression or anxiety secondary to chronic obstructive pulmonary disease (COPD):  acupressure reduced Anxiety and Dyspnea more than “sham” acupressure (done at different points on the body than the “true” procedure)
  87. 87. CAM THERAPIES FOR LATE-LIFE SLEEP DISORDERS  Biologically Based CAM Treatments:  Melatonin:  A recent meta-analysis of the effects of melatonin on primary insomnia showed possible slight improvements in sleep latency, and  this effect was significantly more pronounced in persons with Delayed sleep phase syndrome (i.e., “night owls”).  Studies among older adults have yielded mixed results.
  88. 88. OTHER BIOLOGICALLY BASED TREATMENTS  Only one other RCT of any herb or supplement for Late-life Insomnia was identified in a recent systematic review  a trial comparing Complex mixtures of  20 Chinese botanical products with prescription Estazolam (1 to 2 mg at bedtime).  only a single-dose comparison with Temazepam , Diphenhydramine, and placebo,   found Valerian equivalent to placebo regarding sedating and psychomotor effects.  available evidence favored Valerian over Placebo.  more data on efficacy and safety would be needed
  89. 89.  Mind–Body Therapies:  In a review of the global scientific evidence base,..  only Psychological Symptom for which the evidence of efficacy was considered strong was Insomnia.  Several meta-analyses, including over 4,000 participants, have consistently shown  benefits for mind–body therapies such as relaxation techniques for insomnia
  90. 90.  Relaxation Therapy:   two out of three RCTs reporting positive results on efficacy of relaxation therapies in late-life insomnia .  One positive study found a program of home-based Audiotape Relaxation Treatment = CBT,  (both were bettter than the wait-list condition),  other positive study reported equivalent efficacy comparing  Four weekly individual Relaxation Training Sessions with another evidence-based technique termed Stimulus Control.  (which entails “avoiding sleep-incompatible behaviors in bed, establishing a consistent wake time, and avoiding naps”).
  91. 91.  Music Therapy:  Only one RCT for music therapy,  this trial was positive,  But the control condition and the blinding methods were too poor to draw firm conclusions.  Yoga:  only one RCT testing ..:   among Institutionalized Older Adults in India   yoga to be more effective for self-reported improvements in sleep than both an Ayurvedic medicinal prescription and a wait-list condition.
  92. 92.  Tai Chi  Tai chi (or taiji) is a form of qigong exercise  an ancient Chinese practice reported above to have preliminarily positive effects in a small trial for depression in older persons with chronic pain.  Yang style tai chi :  proved more effective for subjective sleep quality than a stretching exercise control group.
  93. 93. ENERGY-BASED CAM THERAPIES  NCCAM includes  use of Western-based, more scientifically proven forms of energy manipulation (e.g., use of visible light) and  seemingly more esoteric Eastern concepts of energy manipulation (e.g., various manipulations of qi).  Light Therapy:...  the longer duration of early morning bright light therapy,  proved more effective than  the shorter version on subjective and actigraphy-measured parameters of sleep latency and total sleep time as well as on self- reported daytime fatigue.
  94. 94.  Auricular Therapy:   an approach taken from traditional Chinese medicine,   relies on stimulating various well-defined points on the auricle (outer ear).  with needles (auricular acupuncture),  but another novel approach:  with use of Magnets (usually in the form of magnetic pearls) over certain auricular points,   less traumatic and thus less frightening than needle insertion to some people.   focus on the outer ear mirrors Iridology,  (representations of the entire body are considered to exist on one particular body part).
  95. 95.  Acupuncture:  A 2007 Cochrane review of acupuncture for insomnia in persons of all ages found   no convincing evidence of efficacy.
  96. 96. BODY-BASED/MANIPULATIVE THERAPIES  Massage:  finding that massage (with or without aromatherapy) was more effective than treatment as usual for sleep disturbances.  Acupressure:  An RCT..,   it was more effective than “sham” acupressure and  a control of simple attention/conversation for overall sleep quality and several subcomponents of sleep.
  97. 97. CAM THERAPIES FOR SEVERE MENTAL ILLNESS IN LATE-LIFE  Bipolar Disorder:  quality studies of CAM therapies in late-life bipolar disorder are virtually nonexistent.  The most researched CAM therapy in bipolar disorder is the use of omega-3 fatty acid supplements (DHA and EPA).  *The rationale for examining:  1. similar effects of omega-3 fatty acids on second messenger systems as those seen with divalproex and lithium;  2. epidemiological studies linking  increased risk of bipolar disorder with low consumption of omega-3 fatty acids; and  3. cross-sectional studies showing  lower serum levels of omega-3 fatty acids in bipolar patients compared to those of controls.
  98. 98.  But results are Mixed.  one RCT among Young Adults with Bipolar and Unipolar Depression found positive effects for  a supplement called “Free and Easy Wander Plus” (FEWP), a combination of 11 traditional Chinese botanical products.  a CAM therapy in an RCT for Bipolar Disorder was the NIMH Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD),   compared Lamotrigine, Risperidone, and Inositol (a sugar derivative with effects on intracellular signaling)  as Augmentation for Resistant Bipolar Depression (to a mood stabilizer and one or more antidepressants).  overall response rates were abysmal
  99. 99.  Schizophrenia:  As with bipolar disorder,  the phenomenology and treatments for late-life psychotic disorders have received relatively little attention until the past decade,  And, well-conducted studies of CAM therapies for schizophrenia in older adults simply do not exist.
  100. 100.  But, there have been several interesting CAM RCTs in younger persons with schizophrenia, some with potential relevance and interest for older adults:  Ginkgo biloba:  Two studies  the Immunomodulatory and Antioxidant effects of Ginkgo on the participants with Schizophrenia correlated with improvements in overall psychopathology.  Two other Chinese double-blind RCTs:  improvements in Positive symptoms, Extrapyramidal side effects, overall Psychopathology, and Negative symptoms when Ginkgo was added to standard Neuroleptic therapy.
  101. 101.  Omega-3 fatty acids:  possible 2 mechanisms of action,  Anti-inflammatory properties and  Effects on neuronal membrane phospholipids,  have been tied to theories of the biological diatheses for many such disorders.  Cochrane database review in 2006 concluded that  data are still too inconsistent..
  102. 102.  Amino acids - Glycine and D-serine:  a (2006) Cochrane database review concluded somewhat more positive potential.  both act as Co-agonists on the Glutamate N-methyl-D- aspartic acid (NMDA) Receptor and  have shown modest efficacy in several trials for ameliorating Negative symptoms (e.g., avolition and apathy) associated with Schizophrenia.  But, may risk glutamate-associated excitotoxicity,  use of Indirect agonists such as Glycine and D-serine is appealing.
  103. 103.  A variety of other CAM therapies have at least one controlled study in younger adults with schizophrenia with limited relevance:  Music therapy,  Yoga, Chromium,  “Body-oriented” psychotherapy (similar to dance therapy),  Vitamin C, Megavitamins, and  Chinese medicinal herbs.
  104. 104. VARIOUS OTHER CAM THERAPIES NOT DISCUSSED IN THIS SECTION Alexander technique Art therapy Bach flower remedies Biofeedback Black cohosh supplements Chamomile tea Chelation therapy Curanderismo Dance therapy Distant healing Ginger supplements Homeopathy Pet therapy Polarity therapy Probiotics Reiki Saw palmetto supplements Selenium supplements Shaman healing Transcutaneous nerve stimulation
  105. 105. FUTURE DIRECTIONS AND CONCLUSIONS  very few instances can be cited in which a CAM therapy could be reliably recommended as a more Effective (or - as effective) and Safer treatment than conventional treatments..  ?clearest exception is  for Late-life insomnia, where evidence is fairly solid that  their efficacy is equal to conventional treatments and where safety issues likely favor mind–body therapies over prescription sedative-hypnotics.  But, there are also many illnesses for which,  neither CAM nor Conventional medicine have proven themselves to provide the desired level of relief or cure.
  106. 106.  also, no biologically active CAM agent can currently be recommended as a reliably effective and safe treatment for late-life depression or anxiety.  But, high-quality prospective trials of several biological CAM therapies for depression and anxiety are forthcoming with increased NIH funding.  maintaining clinical competency will require attention to results of these trials.
  107. 107.  CAM use has shown no signs of decreasing, even with several well-publicized, negative NCCAM-funded trials.  Aging Baby Boomers are high users of CAM and may well carry their health beliefs and practices with them into old age.  -Increase in the number of older adults with mental illnesses, and psychological symptoms are consistently found to predict increased CAM use.
  108. 108.  Which heightens the importance that Mental health and Primary care Clinicians,  to assess Older adults' use of CAM and  the possible interactions with conventional treatments.  And what clinicians follow, will likely be  a rapidly evolving landscape in the evidence base of CAM therapies for Neuropsychiatric disorders.
  109. 109.  Research by NCCAM will hopefully provide  important answers to many of the questions that remain and  to have much less use of the words “unknown,” “inconclusive,” and “methodologically flawed.”   because even most open-minded traditional medical practitioners will want proof that  they are not simply providing placebo treatments or,  worse still, that they are not violating the cardinal rule of “Do no harm.”
  110. 110.  There are certainly challenges for CAM research that must be confronted, especially for  Nonbiologically based treatments for which control groups are not so easily constructed.  there is no simple placebo pill control.  Yet, research in conventional psychosocial therapies has faced some similar challenges and has managed to overcome many of them.
  111. 111. CHALLENGES IN CAM RESEARCH AND POSSIBLE STRATEGIES FOR OVERCOMING THEM Challenge Possible Strategy Separation of health systems /populations Inadequate control groups Inadequate blinding Collaborations between CAM practitioners/researchers and conventional medical researchers; exploration of baseline differences in characteristics of people’s choice of treatments; consider using preference trials or evaluating treatment preference effects.. Attempt to use controls that possess similar nonspecific elements (credibility, time/attention); assess treatment credibility in participants; if nonspecific effects are considered integral to the holistic CAM treatment, consider pragmatic effectiveness trials versus evidence-based conventional treatments; less of a problem with biologically based treatments that can use placebo pills Outcome assessments, always be conducted by blinded third parties; assess for any differences between groups in treatment credibility and, the participant–practitioner relationship
  112. 112. CHALLENGES IN CAM RESEARCH AND POSSIBLE STRATEGIES FOR OVERCOMING THEM Challenge Possible Strategy Different diagnostic systems Individualized vs. standardized treatments Conflicts of interest Consider standardized conventional inclusion/exclusion criteria, but ? participants in the CAM arm may then be treated according to a different (but reproducible) CAM diagnostic construct Individualization is critical to many CAM treatments; consider flexible yet reproducible protocols (“toolbox approaches”) that have been used in some conventional psychosocial intervention trials As with the conflicts of interest for researchers involved in pharmaceutical trials, possible conflicts of interest exist for CAM researchers and the field would be helped by a common protocol to acknowledge any potential conflicts of interest (financial or otherwise)
  113. 113. THANKS
  114. 114. INTRODUCTION  The science and art of “healing” as well as concepts of “illness” have always been significantly influenced by  the cultural context in which they developed.  What most Western medical practitioners conceive of as “health care” is actually quite in its infancy compared to  many practices – that developed across the world for many centuries past.
  115. 115.  Major advances in biomedical research and in the scientific method in general over the last century have brought the discovery of revolutionary medical interventions that have saved countless lives.  Yet, many practitioners and patients alike sense that the biological and reductionist concepts of illness and its treatment  that have come to guide much of Western medical care  often minimize the role of psychosocial factors in health and wellness  Psychiatry itself, supposed champion among medical fields in addressing psychosocial etiologies of illness, has also become increasingly biological in its focus.
  116. 116.  Other studies have confirmed that users of CAM frequently have chronic illnesses,  many of which are only partially relieved by conventional medical treatments.  E.g. Chronic pain, many psychiatric illnesses, certain forms of cancer, and dementia..  Many of these chronic conditions are age-related,  and older adults over the upcoming decades will be living with currently incurable, often debilitating illnesses.  Also, the generation of Americans that appears to use CAM most frequently is the “Baby Boomers,” who will soon be a part on this surging population of older adults.    these circumstances warrant a review of CAM and its use in geriatric psychiatry.
  117. 117.  Western concept of CAM encompasses,  range of practices, philosophies, and techniques,  Commonly they share a general lack of acceptance and/or use in conventional Western medical settings.  still, as attitudes and evidence bases change,  one day CAM may later be mainstream practice.  Although the above description implies possible negative outcomes of an overly reductionistic approach to health care,   most conventional practitioners who are open to considering the merits of certain CAM therapies,  appreciate that there must be some means of objectively evaluating the efficacy and safety of CAM.
  118. 118.  Acknowledgement of limits of conventional health care and  willingness to consider other cultural and unfamiliar philosophical approaches to health and illness,  also require simultaneous awareness of charlatanism(dishonesty), conflicts of interest, and  possible unknown toxicities that exist in certain CAM practices.
  119. 119.  Persons with Mental Disorders  In national samples of general adult populations,  persons with depression and anxiety (especially panic disorder) symptoms use CAM therapies more.   E,g.  Biological supplements, including herbs, mind–body practices, and spiritual practices  were the most commonly used therapies by those with depression, anxiety, or both.  raising concerns for how these treatments - interact with conventional psychiatric treatments. 